Role of interferon alfa-2b in the induction and maintenance treatment of low-grade non-Hodgkin's lymphoma: results from a prospective, multicenter trial with double randomization

Advances and perspectives of dendritic cell-based active immunotherapies in follicular lymphoma

Follicular lymphoma (FL) is a remarkably immune-responsive malignancy, which is still considered incurable. As, standard immunochemotherapy is complex, toxic and not curative, improvement in FL care is now a crucial topic in hemato-oncology. Recently, we and others have shown that dendritic cell (DC)-based therapies allow a specific immune response associated with sustained lymphoma regression in a proportion of low-tumor burden FL patients. Importantly, the rate of objective clinical response (33-50%) and of sustained remission is remarkably higher compared to similar studies in solid tumors, corroborating the assumption of the immune responsiveness of FL. Our experimental intra-tumoral strategy combined injection with rituximab and interferon-α-derived dendritic cells (IFN-DC), a novel DC population particularly efficient in biasing T-helper response toward the Th1 type and in the cross-priming of CD8 + T cells. Noteworthy, intra-tumoral injection of DC is a new therapeutic option based on the assumption that following the induction of cancer-cell immunogenic death, unloaded DC would phagocytize in vivo the tumor associated antigens and give rise to a specific immune response. This approach allows the design of easy and inexpensive schedules. On the other hand, advanced and straightforward methods to produce clinical-grade antigenic formulations are currently under development. Both unloaded DC strategies and DC-vaccines are suited for combination with radiotherapy, immune checkpoint inhibitors, immunomodulators and metronomic chemotherapy. In fact, studies in animal models have already shown impressive results, while early-phase combination trials are ongoing. Here, we summarize the recent advances and the future perspectives of DC-based therapies in the treatment of FL patients.

Does maintenance therapy have a role in mantle cell lymphoma treatment?

INTRODUCTION

Mantle cell lymphoma (MCL) is a rare but often aggressive B-cell non-Hodgkin lymphoma (NHL). Initial therapy can achieve high response rates but invariably patients relapse and die from their disease. Incorporating a maintenance phase into the treatment strategy may prolong remission duration and ultimately prolong survival. Areas covered: The current literature incorporating a maintenance phase into treatment strategies for newly diagnosed and pre-treated MCL patients has been summarized. A literature search was performed using search terms 'mantle cell lymphoma', 'indolent NHL', 'maintenance', 'interferon', 'rituximab', 'lenalidomide', 'bortezomib' and 'ibrutinib'. Relevant conference proceedings and on-going clinical trial databases were also searched. Expert commentary: There have been few significant trials evaluating the use of maintenance therapy in the context of MCL. Of those performed only rituximab has a significant body of evidence to support it's use and it's benefit is confined to use after certain specific therapies. Of the newer drugs ibrutinib is the most active of the single agents being used in this condition and it is given as continuous therapy to patients who respond to it. How it will be used precisely in a maintenance approach needs to be better defined and is the subject of on-going clinical trials.

Bayesian hierarchical methods for meta-analysis combining randomized-controlled and single-arm studies

Meta-analysis of interventions usually relies on randomized controlled trials. However, when the dominant source of information comes from single-arm studies, or when the results from randomized controlled trials lack generalization due to strict inclusion and exclusion criteria, it is vital to synthesize both sources of evidence. One challenge of synthesizing both sources is that single-arm studies are usually less reliable than randomized controlled trials due to selection bias and confounding factors. In this paper, we propose a Bayesian hierarchical framework for the purpose of bias reduction and efficiency gain. Under this framework, three methods are proposed: bivariate generalized linear mixed effects models, hierarchical power prior model and hierarchical commensurate prior model. Design difference and potential biases are considered in all models, within which the hierarchical power prior and hierarchical commensurate prior models further offer to downweight single-arm studies flexibly. The hierarchical commensurate prior model is recommended as the primary method for evidence synthesis because of its accuracy and robustness. We illustrate our methods by applying all models to two motivating datasets and evaluate their performance through simulation studies. We finish with a discussion of the advantages and limitations of our methods, as well as directions for future research in this area.

Long-term follow up of the FL2000 study comparing CHVP-interferon to CHVP-interferon plus rituximab in follicular lymphoma

Anti-CD20-containing chemotherapy regimens have become the standard of care for patients with follicular lymphoma needing cytotoxic therapy. Four randomized trials demonstrated a clinical benefit for patients treated with rituximab. However, no long-term follow up (i.e. > 5 years) of these trials is yet available. Between May 2000 and May 2002, 358 newly diagnosed patients with high tumor burden follicular lymphoma were randomized to receive cyclophosphamide, adriamycin, etoposide and prednisolone plus interferon-α2a or a similar chemotherapy-based regimen plus rituximab, and outcome was up-dated. With a median follow up of 8.3 years, addition of rituximab remained significantly associated with prolonged event-free survival (primary end point) (P=0.0004) with a trend towards a benefit for overall survival (P=0.076). The Follicular Lymphoma International Prognostic Index score was strongly associated with outcome for both event-free and overall survival in univariate analysis and its prognostic value remained highly significant after adjusting for other significant covariates in multivariate models (P<0.0001 and P=0.001, respectively). Considering long-term toxicity, the addition of rituximab in the first-line setting was confirmed as safe with regards to development of secondary malignancies. Long-term follow up of patients with follicular lymphoma treated in the FL2000 study confirms the sustained clinical benefit of rituximab without long-term toxicity.

Cancer immunotherapy

Cancer immunotherapy consists of approaches that modify the host immune system, and/or the utilization of components of the immune system, as cancer treatment. During the past 25 years, 17 immunologic products have received regulatory approval based on anticancer activity as single agents and/or in combination with chemotherapy. These include the nonspecific immune stimulants BCG and levamisole; the cytokines interferon-α and interleukin-2; the monoclonal antibodies rituximab, ofatumumab, alemtuzumab, trastuzumab, bevacizumab, cetuximab, and panitumumab; the radiolabeled antibodies Y-90 ibritumomab tiuxetan and I-131 tositumomab; the immunotoxins denileukin diftitox and gemtuzumab ozogamicin; nonmyeloablative allogeneic transplants with donor lymphocyte infusions; and the anti-prostate cancer cell-based therapy sipuleucel-T. All but two of these products are still regularly used to treat various B- and T-cell malignancies, and numerous solid tumors, including breast, lung, colorectal, prostate, melanoma, kidney, glioblastoma, bladder, and head and neck. Positive randomized trials have recently been reported for idiotype vaccines in lymphoma and a peptide vaccine in melanoma. The anti-CTLA-4 monoclonal antibody ipilumumab, which blocks regulatory T-cells, is expected to receive regulatory approval in the near future, based on a randomized trial in melanoma. As the fourth modality of cancer treatment, biotherapy/immunotherapy is an increasingly important component of the anticancer armamentarium.

Treatment strategies in advanced stage follicular lymphoma

Although the introduction of anti-CD20 monoclonal antibodies has improved the outcome of patients with follicular lymphoma, a curative treatment is still not available. Many questions still remain to be answered: when should treatment be initiated? Is there an optimal first line treatment and can this treatment be individualized on the basis of prognostic markers? What is the best treatment strategy for relapsed follicular lymphoma and what is the place of the many novel agents? Should maintenance treatment be given to all patients and how? In the present review we will address these questions.

Identification of potential surrogate end points in randomized clinical trials of aggressive and indolent non-Hodgkin's lymphoma: correlation of complete response, time-to-event and overall survival end points

BACKGROUND

The correlation between efficacy end points in randomized controlled trials (RCTs) of systemic therapy for non-Hodgkin's lymphoma (NHL) was investigated to identify an appropriate surrogate end point for overall survival (OS).

METHODS

RCTs of previously untreated NHL published from 1990 to 2009 were identified. Associations between absolute differences in efficacy end points were determined using nonparametric Spearman's rank correlation coefficients (r(s)).

RESULTS

Thirty-eight RCTs representing 85 treatment arms for aggressive NHL and 20 RCTs representing 42 arms for indolent NHL were included. For aggressive NHL, differences in 3-year progression-free survival (PFS)/event-free survival (EFS) were high correlated with differences in 5-year OS {r(s) of 0.90 [95% confidence interval (CI) 0.73-0.96]} and linear regression determined that a 10% improvement in 3-year EFS or PFS would predict for a 7% ± 1% improvement in 5-year OS. For indolent histology disease, differences in complete response were strongly correlated with differences in 3-year EFS [r(s) 0.86 (95% CI 0.35-0.97)], but there was no correlation between 3-year time-to-event end points and 5-year OS.

CONCLUSIONS

Improvements in 3-year EFS/PFS are highly correlated with improvements in 5-year OS in aggressive NHL and should be explored as a candidate surrogate end point. Definition of these relationships may inform future clinical trial design and interpretation of interim trial data.

Interferon-alpha for maintenance of follicular lymphoma

BACKGROUND

Indolent non-Hodgkin's lymphoma, in particular follicular lymphoma (FL), is characterized by multiple remissions and relapses. Several studies have used interferon-alpha (IFN) to control this disease, both as induction and as maintenance therapy. It is not yet clear whether IFN can be associated with a survival benefit although it may prolong progression-free survival.

OBJECTIVES

To determine the effects of IFN in the maintenance therapy of FL.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2008), MEDLINE (1966 to 2008), DARE (1990 to 2008), SCOPUS (searched December 2008) and Current Contents (1975 to 2008). .

SELECTION CRITERIA

Randomised controlled trials of IFN versus no intervention or placebo, or IFN plus chemotherapy versus chemotherapy alone, in a maintenance setting in patients with non-Hodgkin's FL. Primary outcomes were overall survival and progression-free survival.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse events information from the trials.

MAIN RESULTS

We included eight trials (1563 patients). The drug was IFN alfa-2b in six trials and alfa-2a in two. Trials were heterogeneous in terms of diagnosis of FL, using several classification systems. IFN had been compared with placebo/no intervention in five trials and other chemotherapy in three. The effect of IFN was similar to that of placebo on overall survival (hazard ratio (HR) 0.90, 95% CI 0.61 to 1.34) whereas IFN was more effective when added to chemotherapy (HR 0.68, 95% confidence interval (CI) 0.52 to 0.90). Considering IFN versus all comparators, IFN was effective in prolonging progression-free survival (HR 0.66, 95% CI 0.57 to 0.77) and overall survival (fixed effects HR 0.79, 95% CI 0.67 to 0.94, I(2) = 52%). After adjustment for heterogeneity this statistically significance disappeared (random effects HR 0.82, 95% CI 0.63 to 1.08). Toxicity and patients lost to follow up were significantly higher in the IFN groups.

AUTHORS' CONCLUSIONS

There is evidence that addition of IFN as maintenance therapy for FL improves progression-free survival. A net benefit for overall survival is less evident. In the included studies, IFN was associated with significant toxicities that may have a major impact on a patient's quality of life.

Follicular lymphoma: a historical overview

Lymphoma was first described in 1862 and follicular lymphoma in 1925. Initially considered a benign disorder, and named Brill - Symmers disease after the authors of the original papers, it was rapidly recognized as a malignancy with a variable but often indolent course. Most of its clinical features were described by the early 1940s. Despite discussion about its cell of origin, and in contrast to many other lymphoma subtypes, follicular lymphoma could always be accurately recognized and diagnosed using light microscopy morphological features. B-cell origin was demonstrated in the 1970s and the important role of t(14;18) and bcl-2 gene rearrangement in the pathogenesis of follicular lymphoma was established shortly thereafter. The etiology of follicular lymphoma, the reason for marked geographic variation in its incidence, the role of alternative molecular pathways in its pathogenesis, and the cause for its variable clinical behavior all remain unknown. Several observations suggest an important role for the normal immune response in regulating the clinical behavior of follicular lymphoma. From the earliest descriptions, radiation therapy was shown to be very effective in follicular lymphoma, but not curative. Combination chemotherapy was tested in the 1970s, but despite high rates of response, there was only minimal impact on survival. Interferon combined with anthracycline based chemotherapy was the first treatment to improve survival, but was not widely adopted in the USA. Randomized studies have shown an impact of autologous transplantation on progression free survival. Allogeneic transplantation is a curative therapy, but is too toxic for widespread application. Targeted therapies, particularly rituximab have revolutionized the treatment of follicular lymphoma. A convergence of technological and biological advances will likely lead to further dramatic progress in the next decade. For the first time consistent improvements in survival of follicular lymphoma are reported.

Rituximab combined with chemotherapy and interferon in follicular lymphoma patients: results of the GELA-GOELAMS FL2000 study. Blood. 2008;112:4824-4831. [PMID: 18799723 DOI: 10.1182/blood-2008-04-153189]

The FL2000 study was undertaken to evaluate the combination of the anti-CD20 monoclonal antibody rituximab with chemotherapy plus interferon in the first-line treatment of follicular lymphoma patients with a high tumor burden. Patients were randomly assigned to receive either 12 courses of the chemotherapy regimen CHVP (cyclophosphamide, adriamycin, etoposide, and prednisolone) plus interferon-alpha2a (CHVP+I arm) over 18 months or 6 courses of the same chemotherapy regimen combined with 6 infusions of 375 mg/m(2) rituximab and interferon for the same time period (R-CHVP+I arm). After a median follow-up of 5 years, event-free survival estimates were, respectively, 37% (95% confidence interval [CI], 29%-44%) and 53% (95% CI, 45%-60%) in the CHVP+I and R-CHVP+I arm (P = .001). Five-year overall survival estimates were not statistically different in the CHVP+I (79%; 95% CI, 72%-84%) and R-CHVP+I (84%; 95% CI, 78%-84%) arms. In a multivariate regression analysis, event-free survival was significantly influenced by both the Follicular Lymphoma International Prognostic Index score (hazard ratio = 2.08; 95% CI, 1.6%-2.8%) and the treatment arm (hazard ratio = 0.59; 95% CI, 0.44%-0.78%). With a 5-year follow-up, the combination of rituximab with CHVP+I provides superior disease control in follicular lymphoma patients despite a shorter duration of chemotherapy. This study's clinical trial was registered at the National Institutes of Health website as no. NCT00136552.

Rituximab maintenance in indolent lymphoma: indications and controversies

Over the past few years it has been shown in previously untreated and relapsed/refractory follicular lymphoma that rituximab maintenance has a clear clinical benefit after induction with rituximab plus chemotherapy, chemotherapy alone, or rituximab monotherapy. However, the optimal dose, schedule, and duration of rituximab maintenance therapy still need to be established. The important issue of maintenance treatment versus retreatment upon relapse is the topic of the ongoing large randomized phase III Rituximab Extended Schedule or Retreatment Trial (RESORT). Current data indicate that rituximab maintenance can be safely administered for up to 2 years, although assessment of long-term safety requires longer follow-up.

Salvage Chemotherapy in Follicular Non-Hodgkin's Lymphoma: Focus on Tolerability

Follicular lymphoma (FL) is typically characterized by repeated remissions and relapses, and many patients receive a number of therapeutic interventions during their disease course. Although treatment options are evolving rapidly, stem cell transplantation offers a potentially favorable impact on survival. In general, many patients with FL are not eligible for this approach by virtue of age and/or comorbid disease. Salvage chemotherapy consequently remains the mainstay of treatment, being individualized according to disease and patient characteristics, goals of therapy, and patient preference. Many of the cytotoxic agents used in relapsed FL are highly myelotoxic, leading to significant morbidity and mortality, including febrile neutropenia, hemorrhage, and impaired quality of life. Nausea and vomiting can also be problematic, particularly with regimens incorporating carmustine, cisplatin, and high-dose cyclophosphamide. Other acute toxicities include mucositis, alopecia, extravasation injuries, and neurotoxicity. Late toxicities can also occur, sometimes months or even years after the administration of antineoplastic agents. Acute myeloid leukemias, myelodysplastic syndromes, or solid tumors can occur after chemotherapy with alkylating agents. The cardiotoxic profile of anthracycline antibiotics is well recognized, and several agents, including carmustine and cyclophosphamide, can cause lung injury. Persistent neurotoxicity, nephrotoxicity, ototoxicity, and vascular toxicity have also been reported in association with chemotherapeutic agents used in patients with relapsed FL. Novel therapeutic strategies might allow patients to achieve longer remissions, potentially reducing lifetime exposure to repeated cycles of chemotherapy and their attendant toxicities. These could include the use of more efficient preparative and purging approaches in the transplantation setting or the administration of rituximab maintenance therapy after (immuno) chemotherapy induction or transplantation.

Rituximab maintenance improves clinical outcome of relapsed/resistant follicular non-Hodgkin lymphoma in patients both with and without rituximab during induction: results of a prospective randomized phase 3 intergroup trial

We evaluated the role of rituximab (R) both in remission induction and maintenance treatment of relapsed/resistant follicular lymphoma (FL). A total of 465 patients were randomized to induction with 6 cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) (every 3 weeks) or R-CHOP (R: 375 mg/m(2) intravenously, day 1). Those in complete remission (CR) or partial remission (PR) were randomized to maintenance with R (375 mg/m(2) intravenously once every 3 months for a maximum of 2 years) or observation. R-CHOP induction yielded an increased overall response rate (CHOP, 72.3%; R-CHOP, 85.1%; P < .001) and CR rate (CHOP, 15.6%; R-CHOP, 29.5%; P < .001). Median progression-free survival (PFS) from first randomization was 20.2 months after CHOP versus 33.1 months after R-CHOP (hazard ratio [HR], 0.65; P < .001). Rituximab maintenance yielded a median PFS from second randomization of 51.5 months versus 14.9 months with observation (HR, 0.40; P < .001). Improved PFS was found both after induction with CHOP (HR, 0.30; P < .001) and R-CHOP (HR, 0.54; P = .004). R maintenance also improved overall survival from second randomization: 85% at 3 years versus 77% with observation (HR, 0.52; P = .011). This is the first trial showing that in relapsed/resistant FL rituximab maintenance considerably improves PFS not only after CHOP but also after R-CHOP induction.

Phase III intergroup study of fludarabine phosphate compared with cyclophosphamide, vincristine, and prednisone chemotherapy in newly diagnosed patients with stage III and IV low-grade malignant Non-Hodgkin's lymphoma

PURPOSE

To compare the efficacy and safety of fludarabine phosphate with cyclophosphamide, vincristine, and prednisone (CVP) in 381 previously untreated, advanced-stage, low-grade (lg) non-Hodgkin's lymphoma (NHL) patients in a phase III, multicenter study.

PATIENTS AND METHODS

Between 1993 and 1997, patients were randomly assigned to treatment with either fludarabine (25 mg/m2 intravenously [IV] daily for 5 days every 4 weeks) or CVP (cyclophosphamide 750 mg/m2 IV on day 1; vincristine, 1.4 mg/m2 IV on day 1; and prednisone, 40 mg/m2 orally on days 1 through 5 every 4 weeks). Results Overall response (OR) rates were significantly improved in the fludarabine arm versus the CVP arm, both for the intent-to-treat (ITT) population and assessable patients (P < .001). Complete response (CR) rates in the ITT population were also higher after fludarabine treatment. The CR rate was 38.6% for fludarabine compared with 15.0% for CVP. There were no statistically significant differences in time to progression (TTP), time to treatment failure (TTF), and overall survival (OS) between treatment groups. WHO grades 3 and 4 hematologic adverse events were more common in the fludarabine arm. However, concerning the higher incidence of granulocytopenia, this did not translate to more infections in fludarabine-treated patients.

CONCLUSION

Newly diagnosed lgNHL patients who received fludarabine achieved higher OR and CR rates compared with CVP-treated patients. No differences in TTP, TTF, and OS were noted. Fludarabine is a highly active single agent in lgNHL. Combination therapies incorporating fludarabine are now being further evaluated as first-line therapy in follicular NHL.

Follicular lymphoma: time for a re-think?

Follicular lymphoma (FL) is a malignancy of follicle centre B cells that have at least a partially follicular pattern, and is the commonest type of indolent Non-Hodgkin's lymphoma. Except in the subset of patients with localized disease, FL should still be regarded as an incurable malignancy with a relentless relapsing/remitting course. However, the provocative new data covered by this review (including anti-CD20 antibody therapy, BCL-2, radioimmunotherapy, new chemotherapeutic agents and anti-idiotype vaccination), provides much cause for excitement and guarded optimism. Rituximab represents a novel treatment approach for a variety of disease settings, with a proven excellent efficacy and toxicity profile. Long-term data is required to establish whether its use translates into survival benefit. As the clinical activity of rituximab and other new therapeutic approaches becomes established, it will be important to determine how best to integrate these results into the standard care of patients with follicular lymphoma.

Meta-Analysis to Evaluate the Role of Interferon in Follicular Lymphoma

Purpose

To determine whether interferon (IFN) -α2, when given with or following chemotherapy, influences response rate, remission duration, and survival in newly diagnosed patients with follicular lymphoma.

Patients and Methods

Ten phase III studies evaluating the role of IFN-α2 in 1,922 newly diagnosed patients with follicular lymphoma were analyzed. Updated individual patient data were used to perform meta-analyses for response, survival, and remission duration.

Results

The addition of IFN-α2 to initial chemotherapy did not significantly influence response rate. An overall meta-analysis for survival showed a significant difference in favor of IFN-α2, but also showed significant heterogeneity between studies. Further analyses were carried out in order to explain this heterogeneity, and to define the circumstances in which IFN-α2 prolonged survival. The survival advantage was seen when IFN-α2 was given: (1) in conjunction with relatively intensive initial chemotherapy (2P = .00005), (2) at a dose ≥ 5 million units (2P = .000002), (3) at a cumulative dose ≥ 36 million units per month (2P = .000008), and (4) with chemotherapy rather than as maintenance therapy (P = .004). With regard to remission duration, there was also a significant difference in favor of IFN-α2, irrespective of the intensity of chemotherapy used, IFN dose, or whether IFN was given as a maintenance strategy or with chemotherapy.

Conclusion

When given in the context of relatively intensive initial chemotherapy, and at a dose ≥ 5 million units (≥ 36 × 106 units per month), IFN-α2 prolongs survival and remission duration in patients with follicular lymphoma.

Advances in follicular lymphoma

Follicular lymphoma is a usually indolent lymphoma that responds well to chemotherapy. While multiple treatments show a good response rate, most patients relapse. Emerging therapies, such as antibody therapy and stem cell transplantation, are increasingly being used to try to lengthen response time. This article will review the available treatments for follicular lymphoma and discuss the studies supporting newer strategies of treatment.

Combination of fludarabine and mitoxantrone in untreated stages III and IV low-grade lymphoma: S9501

PURPOSE

To determine the efficacy of combination fludarabine and mitoxantrone (FN) in untreated stages III and IV low-grade lymphoma. The major end point was to estimate progression-free survival (PFS) in all eligible patients.

PATIENTS AND METHODS

Seventy-eight eligible patients were registered. Chemotherapy courses were administered every 4 weeks with mitoxantrone 10 mg/m2 on day 1 and fludarabine 25 mg/m2 on days 1, 2, and 3 for a total of six to eight cycles. Pneumocystis carinii prophylaxis was required.

RESULTS

Seventy-three patients (94%) attained an objective response. Complete remission was demonstrated in 34 patients (44%) and partial remission was demonstrated in 39 patients (50%). With a median follow-up time of 5.5 years, the median PFS was 32 months, with a 4-year PFS rate of 38%. Median survival has not been reached and 88% of all patients are alive at 4 years. The application of the International Prognostic Index and serologic staging showed significant differences in PFS in all risk groups, whereas overall survival was markedly worse for the highest-risk group in either prognostic model. Three prior Southwest Oncology Group trials using a regimen of cyclophosphamide, doxorubicin, vincristine, and prednisone or a combination of prednisone, vincristine, methotrexate, cytarabine, cyclophosphamide, etoposide, nitrogen mustard, vincristine, procarbazine, and prednisone in similar patient populations demonstrated comparable clinical outcome, although the 4-year survival for FN was better. FN was well tolerated, but mild to severe reversible myelosuppression was noted. Other complications were rare.

CONCLUSION

FN is an effective, safe chemotherapy combination for patients with advanced-stage, low-grade lymphoma. Clinical outcomes were comparable to prior published data using anthracycline-based regimens.

Phase II study of fludarabine combined with interferon-alpha-2a followed by maintenance therapy with interferon-alpha-2a in patients with low-grade non-hodgkin's lymphoma

Randomized trials suggest improved disease-free survival in low-grade non-Hodgkin's lymphoma (LGNHL) when interferon is combined with multiagent chemotherapy. This phase II trial was conducted to investigate the feasibility of combining fludarabine monophosphate (fludarabine) and IFN in a regimen for treatment of LGNHL. Twenty-one patients were evaluable. Median age was 55 years, and patients had been treated with an average of 1.7 chemotherapy regimens before enrollment. Patients received 25 mg/m2 of fludarabine intravenously on days 1 through 5 followed by 2 x 10(6) U/m2 of interferon-alpha-2a subcutaneously on days 22 through 26. Cycles were repeated every 4 weeks with delays and dose modifications for significant cytopenias. Patients were restaged after cycles 4 and 8, and those with at least a partial response to therapy were given maintenance therapy consisting of 2 x 10(6) U/m2 interferon-alpha-2a subcutaneously three times per week for 6 months. The overall response rate was 76% with a 25% complete response (CR) rate. Overall response rates were 75% (3/4 with 2 CR's) for chemotherapy-naive patients and 76% (13/17 with 3 CR's) for previously treated patients. Median time to progression was 12 months, and currently two patients are without evidence of progression at a median follow-up of 55 months. Grade III or greater toxicities included neutropenia (39%), anemia (17%), thrombocytopenia (5%), fevers/chills (5%), and fatigue (5%). Fludarabine and interferon can be effectively and safely combined in a regimen with significant activity against LGNHL. A modification of this regimen may be suitable for further study.

Progress and promise in the treatment of indolent lymphomas

In the era of conventional alkylating agent-based chemotherapy, advanced stage indolent lymphoma has been considered incurable. The failure of our traditional therapies to cure these patients, coupled with the indolent course of the disease and the elderly population affected, has fostered a nihilistic attitude about the treatment of these diseases. Twenty years ago, in the absence of interesting alternatives to alkylating agents, judicious use and reuse of alkylators was perhaps the best we could do. There are now many reasons for optimism and excitement in the treatment of these diseases, including the availability of promising agents such as interferon-alpha, the nucleoside analogues, and rituximab. Radioimmunotherapy will also likely play a role in future therapy programs. Allogeneic stem cell transplantation is a high-risk approach that is not an option for all patients, but it has the potential to cure patients, even in the setting of relapse. Mini-allogeneic transplantation may permit an approach to allogeneic transplantation that is better tolerated than standard transplant strategies. In addition to these therapy options, biological insights have provided new options for monitoring patients. Molecular monitoring (polymerase chain reaction for bcl-2) is a stringent measure of short-term treatment efficacy, and one that correlates with durability of remission, i.e., it is a surrogate marker by which to judge treatment efficacy. There used to be a limited number of conventional treatment approaches, which consistently failed. The pendulum has swung. There are now many promising new options. It is time to plan and conduct trials that are geared for success.

Increasing treatment options in indolent non-Hodgkin's lymphoma

There is currently no standard first-line treatment for indolent non-Hodgkin's lymphoma (NHL) because there is no curative treatment. In asymptomatic patients, treatment with chemotherapy does not improve survival compared with a "watch and wait" approach. Improved treatment strategies, with curative intent, are thus required for indolent NHL. Rituximab is effective and well tolerated in the treatment of indolent NHL and can be considered for asymptomatic patients, where the side effects of chemotherapy may outweigh the benefits. In addition, rituximab does not compromise the use of subsequent chemotherapy in patients who relapse. A study of rituximab monotherapy in patients with low-tumor-burden follicular lymphoma has shown high rates of both clinical remission and molecular remission (clearance of bcl-2-positive cells from blood and/or bone marrow). After 2 years, half the patients relapsed, indicating that improved strategies are still required. Efforts to improve the efficacy of rituximab have included repeated administrations of the antibody and combined administration with chemotherapy or interferon-alpha2a. The optimal role of rituximab in first-line therapy for indolent NHL will be determined through randomized clinical trials.

Synchronous high-risk melanoma and lymphoid neoplasia

Large population-based studies have shown a significant association between melanoma and lymphoid neoplasia, particularly non-Hodgkin's lymphoma (NHL) and chronic lymphocytic leukaemia (CLL), that is independent of any treatment received for the initial tumour. This study examines the presentation, diagnosis, treatment and progress of three patients who developed advanced melanoma concurrently with a lymphoid neoplasm (one NHL, two CLLs), in order to illustrate their association, discuss common aetiological factors and examine possible therapeutic options. As it is the melanoma rather than the lymphoid neoplasm that represents the bigger threat to overall survival, initial treatment should be targeted towards this cancer. However, because of the interplay between the diseases and the possible side-effects of the various treatments, the choice of adjuvant therapy requires careful consideration. Immunosuppression associated with chemotherapy may permit a more aggressive course for the melanoma, while locoregional radiotherapy is contraindicated following lymph node dissections. As immunotherapy is of benefit in the treatment of melanoma and has also been recently shown to be effective in the management of lymphoid neoplasia, we instituted interferon-alpha as adjuvant therapy for these patients, thereby utilizing a single agent to treat the dual pathologies. The three patients have now been followed-up for 6 months without evidence of disease recurrence or progression.

A randomized controlled trial to evaluate the role of interferon as initial and maintenance therapy in patients with follicular lymphoma

The purpose of this study was to evaluate the role of interferon as initial and maintenance therapy in patients with newly diagnosed follicular lymphoma. Between 1984 and 1994, 204 patients with newly diagnosed Stage III or Stage IV follicular lymphoma were randomized to receive either, Chlorambucil (CB): 10 mg daily for 6 weeks, followed by a 2-week interval, with 3 subsequent 2-week treatment periods at the same dose, separated by 2-week intervals, or, CB given concurrently with interferon (IFN). IFN was given at a dose of 3 x 10(6)units thrice weekly, subcutaneously, throughout the 18-week treatment period. Responding patients were subsequently randomized to receive maintenance IFN at the dose and schedule described above, or to expectant management. The overall response rate was 161/204 (78%), complete remission being achieved in 24% of patients. Neither the addition of IFN to the initial treatment, nor the use of maintenance IFN influenced response rate, remission duration or survival. This study was undertaken to determine whether IFN, given in combination with, and then subsequent to, CB would alter the clinical course of patients with follicular lymphoma. Disappointingly, this objective was not achieved, no advantage having been demonstrated for the addition of IFN.

Final analysis of the ECOG I-COPA trial (E6484) in patients with non-Hodgkin's lymphoma treated with interferon alfa (IFN-alpha2a) plus an anthracycline-based induction regimen

The Eastern Cooperative Oncology Group (ECOG) performed a prospectively randomized study (E6484) evaluating the use of interferon alfa 2a (IFN-alpha2a) in patients with aggressive low-grade or with intermediate-grade non-Hodgkin's lymphoma (NHL) accruing close to 300 patients between 1985 and 1988. Patients were eligible for study if they had bulky or symptomatic low-grade lymphoma or defined intermediate-grade subtypes. Of 291 patients enrolled, 249 were eligible for analysis. All patients were randomized to receive a four-drug cytotoxic chemotherapy regimen including cyclophosphamide, doxorubicin, vincristine and prednisone in 4-week cycles with or without IFN-alpha2a in addition (COPA vs I-COPA). Treatment was given for up to 8-10 months. This report, at a time when the median follow-up among survivors has reached 12 years, updates the analysis of time to treatment failure (TTF), duration of disease-free survival (DFS), and overall survival. Patients randomized to receive IFN-alpha2a had a prolonged TTF (P= 0.008; median 2.4 vs 1.6 years). DFS for those patients who had complete responses was also longer if IFN-alpha2a had been given (P = 0.035; median 2.7 vs 1.8 years). There was a clinically but not a statistically significant prolongation of overall survival by IFN-alpha2a (P= 0.107; median 7.8 vs 5.7 years). There were fewer deaths over time due to lymphoma in patients receiving IFN-alpha2a (67 vs 80 deaths). A subset analysis, based on disease histology (low-grade, follicular, intermediate-grade), revealed a significant prolongation of TTF in patients receiving IFN-alpha2a with either low-grade (P = 0.002; median 2.4 vs 1.6 years) or follicular (P= 0.01; median 2.5 vs 1.7 years) NHL but not intermediate grade (P = 0.622; median 2.3 vs 1.6 years) NHL. This analysis, performed approximately 12 years after closure of the study to accrual, supports the addition of interferon alfa to an induction cytotoxic chemotherapy regimen including cyclophosphamide and doxorubicin in the treatment of follicular NHL.

Meta-analysis to assess the efficacy of interferon-alpha in patients with follicular non-Hodgkin's lymphoma

The authors wanted to determine whether adding interferon-alpha (IFN-alpha) to chemotherapy regimens, in either induction or maintenance settings, provides additional survival benefits in follicular non-Hodgkin's lymphoma (NHL). A meta-analysis was performed based on published data from randomized controlled clinical trials involving nine separate study populations. Patients receiving IFN-alpha (in either induction or maintenance therapy) had significantly increased 5-year and progression-free survival rates at 3 and 5 years compared with concurrent controls. The advantages of IFN-alpha therapy were most marked in studies using anthracycline-containing induction chemotherapy; in these studies, patients who received IFN-alpha had approximately 20% increased progression-free survival rates compared with controls and a lesser survival advantage. The available literature did not allow a determination of the relative benefit of IFN-alpha in induction or maintenance treatments for NHL or a determination of the optimum duration of IFN-alpha treatment. Although questions remain about its optimal use. IFN-alpha appears to prolong survival time in patients with follicular NHL.

Autologous stem cell transplantation (ASCT) with immunologically purged progenitor cells in patients with advanced stage follicular lymphoma after early partial or complete remission: toxicity, follow-up of minimal residual disease and survival

The role of autologous stem cell transplant (ASCT) in indolent lymphomas is a controversial issue. From 1994 to 1999, we performed ASCT with immunologically purged progenitor cells in 15 patients with advanced stage follicular lymphoma (FL) after early partial or complete remission. Results of the purging strategy and follow-up of minimal residual disease after transplant were analyzed with PCR amplification of bcl-2/IgH rearrangement for the t(14;18) translocation. A comparison of transplanted patients with a group of controls was carried out to evaluate differences in progression-free survival and overall survival. Eighty percent of patients received one chemotherapy regimen before ASCT and were in first remission. All the patients received cyclophosphamide plus hyperfractionated total body irradiation as the conditioning regimen. Nine patients were transplanted with bone marrow (BM) and six with peripheral blood progenitor cells (PBPC). Engraftment was delayed in one patient transplanted with BM. Two patients died during the transplant procedure. Ten of 12 evaluable patients were PCR positive in the BM for bcl-2 rearrangement at diagnosis. Six of them (60%) were still positive after chemotherapy, and one patient was transplanted with a positive hematopoietic product after purging. With a median follow-up of 27 months, six of eight evaluable patients still remain PCR negative in the BM. With a median follow-up of 4.7 years from diagnosis, progression-free survival was 83% (95% CI: 63-100). The risk of disease progression of non-transplanted patients was 19.2 times higher than that of transplanted patients (P = 0.01), but no differences were found in overall survival. Regarding patients in first remission, the risk of relapse was 12.6 times higher in non-transplanted than in transplanted patients (P = 0.04). This procedure seems to offer a good chance to achieve a PCR-negative state and prolonged freedom from recurrence. According to these results, prospective randomized trials are warranted.

Follicular lymphomas--a review of treatment modalities

Follicular lymphoma is the most common low-grade non Hodgkin's lymphoma and represent an homogeneous entity as defined by pathological, molecular and clinical data. This indolent disease is characterised by a slow growth pattern with possible spontaneous regression, is often disseminated but remains incurable with available treatments when disseminated. For localised stages, involved field radiotherapy remains the standard choice but other approaches remain to be investigated. In advanced disease, chemotherapy has been demonstrated to produce high response rates but recent trials with new treatment strategies including interferon and monoclonal antibodies may improve the current situation. In this article, we will review treatment of follicular lymphomas, specially emphasising published phase III trials.

Treatment advances in non-Hodgkin's lymphoma

Non-Hodgkin's lymphomas (NHL) encompass a heterogeneous group of lymphoid malignancies with varying natural histories and prognoses. Recent classifications for NHL have defined distinct lymphoma entities based on morphology, immunophenotype, genetic features, clonal cell lineage and clinical features. These new, more precise classifications and characterizations of NHL will be essential in developing new targeted therapies. However, for this brief review, we will continue describe NHL primarily as indolent or aggressive. Treatment options for patients with indolent, but generally incurable, lymphomas include a 'watch and wait' approach, single agent alkylators, nucleoside analogues, combination chemotherapy, immunotherapy with monoclonal antibodies, radiolabelled monoclonal antibodies, or interferon (IFN). Vaccine therapy for indolent lymphomas is currently under intense investigation. For aggressive lymphomas, combination chemotherapy remains the standard of care. Major advances in the management of aggressive lymphomas include validation of the international prognostic index and clarification of the role of high-dose therapy with bone marrow or stem cell transplant in patients with relapsed aggressive lymphomas. Multiple randomised pilot trials of high dose therapy as initial therapy for aggressive lymphomas have shown conflicting results and await confirmatory studies.

Fludarabine alone compared to CHVP plus interferon in elderly patients with follicular lymphoma and adverse prognostic parameters: a GELA study. Groupe d'Etudes des Lymphomes de l'Adulte

BACKGROUND

Fludarabine was associated with a good response and was well tolerated in patients with follicular lymphoma in phase II trials and this treatment may be associated with less adverse events than treatment with CHVP plus interferon in elderly patients.

PATIENTS AND METHODS

One hundred thirty-one patients older than 59 years with a follicular lymphoma and poor prognosis were randomized between the association of CHVP (12 cycles in 18 months) plus interferon (5 MU TIW for 18 months) or fludarabine alone (25 mg/m2/d x 5 days for 6 cycles, then 20 mg/m2/day for 6 further cycles for 18 months). Poor prognosis was defined by the presence of a large tumor mass, poor performance status, the presence of B symptoms, above normal LDH level, or > or = 3 mg/l beta-microglobulin level.

RESULTS

Patients treated with CHVP plus interferon had a higher response to treatment, a longer time to progression and a longer survival than those treated with fludarabine alone (P < 0.05 for all analyses). With a median follow-up of 29 months, the 2-year failure-free survival was 63% for the CHVP-plus-interferon arm compared to 49% for the fludarabine arm and the two-year survival was 77% and 62%, respectively. This benefit was confirmed in a multivariate analysis including initial prognostic parameters. Fludarabine alone was associated with less neutropenia than CHVP plus interferon. Interferon was decreased or stopped in 39% of the patients because of severe fatigue.

CONCLUSIONS

CHVP plus interferon over 18 months was associated with a better outcome, even though the combination of interferon plus chemotherapy was less well tolerated than fludarabine.

Treatment of follicular and other indolent lymphomas

The understanding of specific lymphoma entities continues to evolve. This is perhaps most clearly illustrated by developments concerning gastric lymphomas of mucosa-associated lymphoid tissue (MALT) origin, ranging from further evidence of the role played by Helicobacter pylori, to new information about the role of an apoptotic regulatory gene, bcl-10. Another area of productive research is the study of the mechanism of immune recognition and death signaling in follicular lymphomas. This should lead to refinements and improvements in an already very promising array of immunotherapeutic approaches, which currently ranges from vaccine development to allogeneic transplant strategies designed to induce a graft-versus-lymphoma effect. The clinical success of the chimeric anti-CD20 antibody, rituximab, leaves no doubt that biologic insights can lead to therapeutic advances. Researchers appear to be breaking free of the notion that alkylating agent therapy is the best option and the only viable treatment strategy for the indolent lymphomas. The current challenge is to apply new insights wisely.

Biologic therapy for lymphoma

Biologic approaches to lymphoma treatment are now a practical reality rather than a vaguely perceived hope for the future. Interferon alfa seems to have been established as a life-extending therapy for selected patients with follicular lymphoma. Humanized anti-CD20 monoclonal antibody (rituximab) has an authentic 50% response rate in patients with follicular lymphoma, frequently works when given a second time, and is demonstrating what seems to be synergistic activity when combined with chemotherapy. Radioimmunoconjugates using iodine-131 and yttrium-90 as payload are producing responses in refractory and aggressive lymphomas. Vaccines and adoptive cellular therapies are also showing promising results in early phase clinical testing.

Hodgkin's disease and non-Hodgkin's lymphoma

The development of new classification schemes and prognostic analyses for lymphomas has helped to identify patients at high risk for relapse who may benefit from intensification of primary therapy. Conventional salvage therapy for relapsed follicular or low-grade lymphomas now includes monoclonal antibody therapy. The combination of chemotherapy and monoclonal antibody therapy may improve outcomes for patients with advanced-stage aggressive non-Hodgkin's lymphomas. Confirmatory randomized trials are now in progress. Therapy for Hodgkin's disease continues to evolve toward the most efficacious programs, which also minimize the long-term probability of toxicity. The combination of high-dose chemotherapy and stem cell transplantation is probably the most effective therapy for patients with relapsed or refractory Hodgkin's disease.

Allogeneic versus autologous bone marrow transplantation for refractory and recurrent low-grade non-Hodgkin's lymphoma: updated results of the Utrecht experience

This study was conducted to compare the results of myeloablative therapy followed either by autologous stem cell transplantation (SCT) or allogeneic SCT for poor-risk low-grade non-Hodgkin's lymphoma. Eighteen patients received autologous SCT and 15 patients received allogeneic SCT. All autologous patients had chemosensitive disease while this was the case in only 8 allogeneic patients. Besides, 14 of 15 allogeneic patients still had overt lymphoma infiltration of the marrow, when SCT took place. Despite these unfavorable characteristics, all allogeneic patients achieved complete remission (CR) with this procedure and, until now, none has relapsed. In contrast, 14 of 18 autologous patients achieved CR with SCT but 11 (79%) relapsed. Four allogeneic patients (27%) had a treatment-related death, whereas this did not occur with autologous SCT. The 3-year probabilities of relapse, overall survival, and event-free survival were 0%, 70% (95% CI, 38-87%), and 70% (95% CI, 38-87%) respectively for allogeneic SCT and 78% (95% CI, 57-93%), 33% (95% CI, 13-54%), and 22% (95% CI, 7-43%) respectively for autologous SCT. The differences in relapse and event-free survival were highly significant, p = 0.0002 and p= 0.015, respectively. These data show that allogeneic SCT leads to prolonged disease-free survival in patients with advanced poor-risk low-grade lymphoma which rarely occurs after autologous SCT. There is substantial evidence for a graft-versus-low-grade lymphoma effect.